NUR 319 Ch 19 Thorax and Lungs Abnormals

Barrel Chest

Note equal AP-to-transverse diameter and that ribs are horizontal instead of the normal downward slope. Associated with normal aging, chronic emphysema, and asthma as a result of hyperinflation of lungs 

Pectus Excavatum

Sunken sternum and adjacent cartilages, depression begins at second intercostal space, becoming depressed most at junction of xiphoid with body of sternum. More noticeable on inspiration. Congenital, usually not symptomatic. When severe, sternal depression may cause embarrassment and a negative self-concept. Surgery may be indicated. 

Pectus Carinatum

A forward protrusion of the sternum, with ribs sloping back at either side and vertical depressions along costochondral junctions (pigeon breast). Less common than pectus excavatum, this minor deformity requires no treatment. If severe, surgery may be indicated. 

Scoliosis

Lateral S-shaped curvature of the thoracic and lumbar spine. Unequal shoulders and scapular height and unequal hip levels. More prevalent in adolescent girls. Is severe (>45 degrees), it may reduce lung volume and puts them at risk for impaired cardiopulmonary function and negative self-image

Kyphosis

Exaggerated posterior curvature of the thoracic spine (humpback) that causes significant back pain and limited mobility. Occurs commonly with aging and in postmenopausal osteoporotic women. Women who do adequate exercise habits are less likely to develop kyphosis

Sigh

Occasional sighs punctuate the normal breathing pattern and are purposeful to expand alveoli. May indicate emotional dysfunction and may lead to hyperventilation and dizziness

Tachypnea

Rapid, shallow breathing. Increased rate >24 per minute. Normal response to fever, fear, or exercise. Also increases with respiratory insufficiency, pneumonia, alkalosis, pleurisy, and lesions in the pons  

Hyperventilation

Increase in both rate and depth. Hyperventilation blows off CO2 causing a decreased level in the blood (alkalosis)

Bradypnea

Slow breathing. Decreased but regular rate

Hypoventilation

Irregular shallow pattern can be caused by overdose of narcotics or anesthetics, prolonged bed rest, or conscious splinting of chest 

Cheyenne-Stokes Respiration

A cycle in which respirations gradually wax and wane in a regular pattern, increasing in rate and depth and then decreasing. The breathing periods last 30 to 45 seconds, with periods of apnea (20 seconds) alternating the cycle. The most common cause is severe heart failure

Biots Respiration

Similar to Cheyne-Stokes respiration, except that the pattern is irregular. A series of normal respirations (3 to 4) is followed by a period of apnea. The cycle length is variable, lasting anywhere from 10 seconds to 1 minute. Seen with head trauma

Chronic Obstructive Breathing

Normal inspiration and prolonged expiration to overcome increased airway resistance. Situations with increased heart rate can lead to air trapping due to a person not having enough time for full expiration.

Increase tactile remits

Occurs with conditions that increase the density of lung tissue, which makes a better conducting medium for vibrations. Must be a patent (open or unobstructed) bronchus, and consolidation must extend to lung surface for increased fremitus to be apparent.

Decrease tactile fremitus

Occurs when anything obstructs transmission of vibrations with palpating hand (obstructed bronchus, pleural effusion or thickening, pneumothorax, and emphysema) 

Rhoncial fremitus

Vibration felt when inhaled air passes through thick secretions in the larger bronchi. Can be decreased by coughing 

Pleural friction fremitus

Produced when inflammation of the parietal or visceral pleura causes a decrease in the normal lubricating fluid. The opposing surfaces make a coarse grating sound when rubbed together during breathing. Best detected by auscultation, but it may be palpable. It is synchronous with respiratory excursion. Also called a palpable friction rub. 

Crackles (fine)

High-pitched, discontinuous, short, cracking, popping during inspiration that is not cleared by coughing 

Crackles (coarse)

Low-pitched, loud, bubbling or gurgling, start in early inspiration, may be present in expiration. May decrease by coughing but reappear shortly after

Atelectatic crackles

Fine crackles, do not last, are not pathological, and disappear after first few breaths. Heard in axillae and bases.

Pleural friction rub

Superficial sound: coarse and low pitched. it has a grating quality as if two pieces of leather are being rubbed together; sounds just like crackles, but close to the ear; sounds louder if you push the stethoscope harder onto the chest wall; sound is inspiratory and expiratory. 

Low pitched wheeze

monophonic, single note, musical snoring, moaning sounds; they are heard throughout the cycle, more prominent on expiration; may clear somewhat by coughing

High pitched wheeze

musical squeaking sounds that sound polyphonic (like a musical cord), predominate in expiration but may occur in both expiration and inspiration 

Stridor

High pitched, monophonic, inspiratory, crowing sound; louder in neck than over chest wall. Originating in larynx or trachea, upper airway obstruction from swollen, inflamed tissues or lodged foreign body.  

Croup and acute epiglottis in children and foreign inhalation; obstructed airway may be life threatening  

Bronchophony

Increased lung density enhances transmission of voice sounds; you auscultate a clear “ninety-nine” - abnormal 

The words are more distinct than normal and sound close to your ear 

Egophony

When auscultating the spoken “eeee” sound changes to a bleating long “aaaaa” sound 

Whisper Pectoriloquy

Ask patient to whisper “one-two-three" as you auscultate. Normal response is faint, muffled, almost inaudible 

Abnormal - with only small amounts of consolidation, the whispered voice is transmitted very clearly and distinctly, although still faint. Sounds like person is whispering right into the stethoscope

Atelectasis (collapse)

Collapsed shrunken section of alveoli or an entire lung (pneumothorax) as result of 1. Airway obstruction, 2. compression on the lung, 3. lack of surfactant. Cough, lag on affected side, increased respiratory rate and pulse, possible cyanosis. Chest expansion decreased on affected side, tactile fremitus decreased or absent, tracheal shift toward affected side. Percussion is dull. Breath sounds decreased vesicular or absent. Voice sounds variable – decreased or absent.  

Lobar Pneumonia

Infection in lung; Decreases surface area of the membrane causing hypoxemia. You will see increased respirations, guarding and lag on expressions, pulse >100, dull sounds over pneumonia, tachycardia, and crackles. 

Acute Bronchitis

An acute infection of the trachea and larger bronchi characterized by cough, lasting up to 3 weeks. Over 90% of cases are viral and do not require antibiotics.

Chronic Bronchitis

Proliferation of mucus glands in the passage­ways, resulting in excessive mucus secretion. Inflammation of bronchi with partial obstruction of bronchi by secretions or constrictions. has a recurrent productive cough, and is typically caused by cigarette smoking.  

Emphysema

Destruction of pulmonary connective tissue characterized by permanent enlarged of air sacs and rupture of interalveolar walls. Presents with barrel chest, accessory muscle use when breathing, SOB, and other signs of respiratory distress. Hyper resonant, usually has no adventitious sounds. 80-90% of cases are cigarette smokers

Asthma

Reactive airway disease. An allergic hypersensitivity to certain inhaled allergens, irritants, microbes, stress, or exercise that causes bronchospasm, inflammation, edema in bronchioles, and mucus secretion. Produces wheezing, dyspnea, and chest tightness. __Sounds:__ bilateral wheezing on expiration, sometimes inspiratory and expiratory wheezing

Pleural Effusion

Collection of excess fluid in intrapleural space with compression of overlying lung tissue. Gravity settles fluid in thorax. Fluid subdues all lung sounds. Most common cause is heart failure; also caused by infection and cancer. __Sounds:__ crackles, pleural rib 

Heart Failure

Pump failure with increasing pressure of cardiac overload causes pulmonary congestion or an increased amount of blood in pulmonary capillaries. Dependent air sacs deflated. Pulmonary capillaries engorged. Bronchial mucosa may be swollen. __Sounds:__ crackles at lung bases

Pneumothorax

unilateral lung collapse. Can be from 1. spontaneous (air enters pleural space through ruptured lung wall) 2. traumatic (injury opening in chest wall) 3. tension (trapped air in pleural spaces compresses lung)

Pneumocystis jiroveci (P. carinii) pneumonia

AIDS; Inspection: Anxiety, SOB, dyspnea on exertion, feeling of discomfort; also tachypnea; fever; a dry, nonproductive cough; intercostal retractions in children; cyanosis; Palpation: Decreased chest expansion; Percussion: Dull over areas of diffuse infiltrate; Auscultation: Breath sounds may be diminished; Adventitious Sounds: Crackles may be present but often are absent.

Tuberculosis

Inhalation of tubercle bacilli into the alveolar wall. Initially asymptomatic, showing as positive skin test or lesions on x-ray study. Progressive TB symptoms weight loss, anorexia, low-grade afternoon fevers, night sweats. May have pleural effusion, recurrent lower respiratory infections. Cough initially nonproductive, later productive of purulent, yellow-green sputum; may be blood tinged. Dyspnea, orthopnea, fatigue, weakness. 

Pulmonary embolism

Undissolved materials (e.g., thrombus or air bubbles, fat globules) originating in legs or pelvis detach and travel through venous system, returning blood to right heart, and lodge to occlude pulmonary vessels. 

Acute Respiratory Distress Syndrome (ARDS)

An acute pulmonary insult (trauma, gastric acid aspiration, shock, sepsis) damages alveolar capillary membrane, leading to increased permeability of pulmonary capillaries and alveolar epithelium and to pulmonary edema. 

Lung Cancer

__squamous__ cell usually starts in central bronchi near the hilus; __adenocarcinoma__ usually starts in the periphery (away from center) and escapes early detection; __large cell__ also starts in the periphery with tumors arranged as clusters; __small cell (oat cell)__ compresses and narrows central bronchi; major cause is tobacco smoking or secondhand smoke.